OFFICIAL MAD RIVER CLUB FISHING DERBY REGISTRATION FORM
SEVENTH ANNUAL STRAWBERRY LAKE KIDS BASS DERBY
SATURDAY AND SUNDAY JULY 18-19, 2009
NAME___________________________________________AGE____
ADDRESS________________________________________________
CITY________________________STATE__________ZIP_________
PHONE___________________________________________________
RELEASE OF LIABILITY/PHOTO RELEASE
As parent or guardian of the above mentioned child, I certify that said child has my permission to attend and participate in the above mentioned Kids Fishing Derby, held on the above date, time and location. In signing this form, I hereby wave and release all other participants, the host, the sponsors, and all other officials or parties involved on the Derby from the claims and/or damage incurred in connection with this Kids Fishing Derby. I also hereby grant the sponsor and co-sponsors the unconditional right to use the name, voice and photographic likeness of the child in connection with any of their audio/video productions, articles, or press releases, but not as an endorsement.
____________________________Date _________ / ______________________________Date __________
Parent/guardian signature Child signature